- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.98 / $246.23 / $246.23
| Facility | | $196.98 | $246.23 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.22 / $246.23 / $246.23
| Professional | | $246.22 | $246.23 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.00 / $284.00 / $284.00
| Professional | | $284.00 | $284.00 | $284.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.78 / $105.78 / $198.68
| Facility | | $51.78 | $105.78 | $198.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.95 / $246.23 / $258.54
| Facility | | $126.95 | $246.23 | $258.54 |